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(BQ) Part 1 book “Sports emergency care” has contents: Introduction to sports emergency care, preparing for sports emergencies, airway management and breathin, assessment of sports emergencies, care concepts in management of the spine-injured athlete, cardiovascular emergencies,… and other contents.
SPORTS EMERGENCY CARE A TEAM APPROACH Third Edition SPORTS EMERGENCY CARE A TEAM APPROACH Third Edition Robb S Rehberg, PhD, ATC, NREMT Jeff G Konin, PhD, ATC, PT, FACSM, FNATA Senior Vice President: Stephanie Arasim Portnoy Vice President, Editorial: Jennifer Kilpatrick Vice President, Marketing: Michelle Gatt SLACK Incorporated 6900 Grove Road Thorofare, NJ 08086 USA 856-848-1000 Fax: 856-848-6091 www.Healio.com/books © 2018 by SLACK Incorporated Acquisitions Editor: Brien Cummings Managing Editor: Allegra Tiver Creative Director: Thomas Cavallaro Cover Artist: Katherine Christie Project Editor: Joseph Lowery All rights reserved No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher, except for brief quotations embodied in critical articles and reviews The procedures and practices described in this publication should be implemented in a manner consistent with the professional standards set for the circumstances that apply in each specific situation Every effort has been made to confirm the accuracy of the information presented and to correctly relate generally accepted practices The authors, editors, and publisher cannot accept responsibility for errors or exclusions or for the outcome of the material presented herein There is no expressed or implied warranty of this book or information imparted by it Care has been taken to ensure that drug selection and dosages are in accordance with currently accepted/recommended practice Off-label uses of drugs may be discussed Due to continuing research, changes in government policy and regulations, and various effects of drug reactions and interactions, it is recommended that the reader carefully review all materials and literature provided for each drug, especially those that are new or not frequently used Some drugs or devices in this publication have clearance for use in a restricted research setting by the Food and Drug and Administration or FDA Each professional should determine the FDA status of any drug or device prior to use in their practice Any review or mention of specific companies or products is not intended as an endorsement by the author or publisher SLACK Incorporated uses a review process to evaluate submitted material Prior to publication, educators or clinicians provide important feedback on the content that we publish We welcome feedback on this work Library of Congress Cataloging-in-Publication Data Names: Rehberg, Robb S., author | Konin, Jeff G., author Title: Sports emergency care : a team approach / Robb S Rehberg, Jeff G Konin Description: Third edition | Thorofare, NJ : SLACK Incorporated, [2018] | Includes bibliographical references and index Identifiers: LCCN 2018022460 (print) | LCCN 2018023187 (ebook) | ISBN 9781630914349 (Epub) | ISBN 9781630914356 (Web) | ISBN 9781630914332 (paperback) Subjects: | MESH: Athletic Injuries therapy | Emergency Treatment Classification: LCC RC1210 (ebook) | LCC RC1210 (print) | NLM QT 261 | DDC 617.1/027 dc23 LC record available at https://lccn.loc.gov/2018022460 For permission to reprint material in another publication, contact SLACK Incorporated Authorization to photocopy items for internal, personal, or academic use is granted by SLACK Incorporated provided that the appropriate fee is paid directly to Copyright Clearance Center Prior to photocopying items, please contact the Copyright Clearance Center at 222 Rosewood Drive, Danvers, MA 01923 USA; phone: 978-750-8400; website: www.copyright.com; email: info@copyright.com DEDICATION For Joelle, Anna, and Joey – you are the greatest joy of my life And for my colleagues, the athletic trainers and EMS professionals who, day in and day out, selflessly help others when they need it the most You are the inspiration for this book —Robb S Rehberg, PhD, ATC, NREMT To Lucy, who provided care for decades without any book to guide you how to it You simply did it —Jeff G Konin, PhD, ATC, PT, FACSM, FNATA CONTENTS Dedication v Acknowledgments ix About the Authors xi Contributing Authors xiii Preface .xv Foreword by Ronnie P Barnes, MS, ATC xvii Chapter Introduction to Sports Emergency Care Robb S Rehberg, PhD, ATC, NREMT Chapter Preparing for Sports Emergencies Robb S Rehberg, PhD, ATC, NREMT and Jim Kyle, MD, FACSM Chapter Assessment of Sports Emergencies 21 Robb S Rehberg, PhD, ATC, NREMT Chapter Airway Management and Breathing 39 Robb S Rehberg, PhD, ATC, NREMT Chapter Cardiovascular Emergencies 53 Robb S Rehberg, PhD, ATC, NREMT Chapter Care Concepts in Management of the Spine-Injured Athlete 63 Ron Courson, ATC, PT, NRAEMT, CSCS; Robb S Rehberg, PhD, ATC, NREMT; and Michele J Monaco, DSc, ATC Chapter Unconsciousness and Seizures 89 David A Middlemas, EdD, ATC, CCISM Chapter Management of Traumatic Brain Injury 103 Casey Christy, MA, ATC, CSCS Chapter Injuries to the Thoracic Region 123 Michael A Prybicien, MA, ATC, PES, CES Chapter 10 Abdominal and Pelvic Injuries 135 David A Middlemas, EdD, ATC, CCISM Chapter 11 Fractures and Soft Tissue Injuries 153 Michael A Prybicien, MA, ATC, PES, CES and Louis Rizio III, MD viii Contents Chapter 12 General Medical Emergencies 173 John L Davis, MS, ATC Chapter 13 Environmental Emergencies 187 Rebecca M Lopez, PhD, ATC, CSCS Chapter 14 Managing Mental Health Emergencies 203 Eileen Lubeck, PsyD Chapter 15 Emergency Care Considerations for the Pediatric and Youth Athlete 213 Rebecca M Lopez, PhD, ATC, CSCS and Jeff G Konin, PhD, ATC, PT, FACSM, FNATA Chapter 16 Care of Athletes With Disabilities 235 Aaron Rubin, MD, FAAFP, FACSM and Lauren M Simon, MD, MPH, FACSM, FAAFP Chapter 17 Emergencies in Sports for the Aging Athlete 245 David Pezzullo, MS, PT, SCS, ATC Appendix Equipment Removal Techniques .255 Financial Disclosures .267 ACKNOWLEDGMENTS Developing Sports Emergency Care: A Team Approach was just that…a team approach There are several people who were instrumental in the development of this book that we wish to thank Without their help, this book would never have been written To the contributing authors: Casey Christy, you have a passion for this subject, and I’m glad we got you involved in this project You are a true professional and a good friend Ron Courson, whose all-around professionalism and leadership is second to none John L Davis (the original “cover boy” for the book), you are a friend, colleague, and role model It meant a lot to have you involved in this project Thanks for everything Dr Jim Kyle, a life-long dear friend of ours who embodies the warmest of hearts and deepest of passion in emergency care Eileen Lubeck, for filling a critical need in this book, and for being a great example of interprofession collaboration Your addition to this book makes it stronger Rebecca M Lopez, for contributing great content on such important topics You were wonderful to work with, and we truly appreciate your expert contributions David A Middlemas, this book is better because of your involvement Thanks for your contribution, your friendship, and your help with the photo shoot David Pezzullo, a true go-getter who simply “gets it,” thanks for your professional friendship Michael A Prybicien, my colleague and longtime friend We have come a long way from those early days in our careers Thanks for being involved in this project and for helping out in so many ways Louis Rizio III, for finding the time in your busy schedule to contribute to this project Your contributions were invaluable Joelle Rehberg, for illustrating much of the line art that appears in this book, for countless hours of manuscript review, and simply for putting up with me in the process Dr Aaron Rubin and Dr Lauren M Simon, whose contributions to this text add a dimension of importance previously overlooked Thanks also to the athletic training faculty and staff at William Paterson University: Linda Gazzillo Diaz, Alison Moquin, and Dondi Boyd, for their never-ending assistance in getting this book off the ground Thanks also to the athletic training students of William Paterson University, especially Matthew Bergh and Tedd Rossillo (who served as models), and the athletic training students and EMS staff at Montclair State University for participating in the photo shoot for this book Special thanks to the staff at SLACK Incorporated that have been involved in this project through the years, including Brien Cummings, Michelle Gatt, Joe Lowery, Allegra Tiver, John Bond, Jennifer Briggs, April Billick, and especially Carrie Kotlar for believing in this book and finally making it happen 120 Chapter REVIEW QUESTIONS What is the difference between a “diffuse” brain injury and a “focal” brain injury? Define concussion Name the components of concussion symptoms and give an example of each What is the difference between an epidural and a subdural hematoma? Describe the proper emergency care for an athlete suspected of having a concussion REFERENCES 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Langlios JA, Rutland-Brown W, Wald M The epidemiology and impact of traumatic brain injury: a brief overview J Head Trauma Rehabil 2006;21(5):375-378 McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K Unreported concussion in high school football players: implications for prevention Clin J Sport Med 2004;14(1):13-17 Gerberich SG, Priest JD, Boen JR, Straub CP, Maxwell RE Concussion incidences and severity in secondary school varsity players Am J Public Health 1983;73(12):1370-1375 Grady MF Concussion in the adolescent athlete Curr Prob Pediatr Adolesc Health Care 2010;40(7):154-169 Cantu RC Posttraumatic retrograde and anterograde amnesia: pathophysiology and implications in grading and safe return to play J Athl Train 2001;36(3):244-248 Thibodeau GA, Patton KT The nervous system In: Structure and Function of the Body 13th ed St Louis, MO: Mosby Elsevier; 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2006:557-578 Bailes JE, Hudson V Classification of sport-related head trauma: a spectrum of mild to severe injury J Athl Train 2001;36(3):236-243 White RJ Subarachnoid hemorrhage: the lethal intracranial explosion Emerg Med Clin North Am 1994;12(2):74 Robinson RG Chronic subdural hematoma: surgical management in 133 patients J Neurosurg 1984;61(2):263-268 Management of Traumatic Brain Injury 121 26 Maddocks DL, Dicker GD, Saling MM The assessment of orientation following concussion in athletes Clin J Sports Med 1995;5(1):32-35 27 McCrea M, Kelly JP, Kluge J, Ackley B, Randolph C Standardized assessment of concussion in football players Neurology 1997;48(3):586-588 28 Oliaro S, Anderson S, Hooker D Management of cerebral concussion in sports: the athletic trainer’s perspective J Athl Train 2001;36(3):257-262 29 McGrath N Supporting the student-athlete’s return to the classroom after a sport-related concussion J Athl Train 2010;45(5):492-498 30 Scorza KA, Raleigh MF, O’Connor FG Current concepts in concussion: evaluation and management Am Fam Physician 2012;85(2):123-132 31 Cantu RC Second impact syndrome: a risk in any contact sport Phys Sports Med 1995;20(12):27-34 32 Boden BP, Tacchetti RL, Cantu RC, Knowles, SB, Mueller FO Catastrophic head injuries in high school and college football players Am J Sports Med 2007;35(7):1075-1081 33 Pellman EJ, Lovell MR, Viano DC, Casson IR Concussion in professional football: recovery of NFL and high school athletes assessed by computerized neuropsychological testing—part 12 Neurosurgery 2006;58(2):263-274 34 McKee AC, Cantu RC, Nowinski CJ, et al Chronic traumatic encephalopathy in athletes: progressive tauopathy after head injury J Neuropathol Exp Neurol 2009;68(7):709-735 35 Broglio SP, Macciocchi SN, Ferrara MS Neurocognitive performance of concussed athletes when symptom free J Athl Train 2007;42(4):504-508 36 Collins M, Lovell, MR, Iverson GL, Maroon IT Examining concussion rates and return to play in high school football players wearing newer helmet technology: a three-year prospective cohort study Neurosurgery 2006;58(2):275-286 37 Makdissi M, Darby D, Maruff P, Ugoni A, Brukner P, McCrory PR Natural history of concussion in sport: markers of severity and implications for management Am J Sports Med 2010;38(3):464-471 Injuries to the Thoracic Region Michael A Prybicien, MA, ATC, PES, CES Shortly before the end of the lacrosse game, one of your players reports to you complaining of a sudden stabbing pain in his right pectoral and lateral axillary regions He tells you he feels out of breath, and his respiratory rate and heart rate are elevated You listen to his breathing with a stethoscope and notice decreased lung sounds on his right side He has no history of respiratory problems, but you noticed he took a hard hit a few minutes earlier in the game He becomes pale, and his skin becomes cool and clammy Upon placing him in the recovery position, he complains that the pain in his chest increases What would you do? Acute thoracic injuries can be among the most serious in sports because they can impose a threat of long-term disability and, in the most severe cases, even death They have the potential to be catastrophic in nature because they can affect the spinal cord; nerves around the spinal cord (which are responsible for motor and sensory activity); and the heart, lungs, and various other organs Fortunately, thoracic injuries are usually nonemergency acute conditions such as sprains, strains, and contusions REVIEW OF CLINICALLY RELEVANT ANATOMY The thorax is a bone cavity that is formed by 12 pairs of ribs that join posteriorly with the thoracic spine and anteriorly with the sternum (Figure 9-1) The intercostal neurovascular bundle runs along the inferior surface of each rib The inner side of the thoracic cavity and the lung itself are lined with a thin layer of tissue called the pleura The space between the pleural layers is normally only a potential space However, this space may be occupied by air, forming a pneumothorax, or blood, forming a hemothorax This potential space can hold L of fluid on each side in an adult 123 Rehberg RS, Konin JG Sports Emergency Care: A Team Approach, Third Edition (pp 123-133) © 2018 SLACK Incorporated 124 Chapter Figure 9-1 Anterior view of the thorax (Illustration by Joelle Rehberg, DO.) One lung occupies each thorax cavity The mediastinum is between the chest cavity and contains the heart, aorta, superior and inferior vena cava, trachea, major bronchi, and esophagus The spinal cord is protected by the vertebral column The diaphragm separates the thoracic organs from the abdominal cavity The upper abdominal organs, including the spleen, liver, kidneys, pancreas, and stomach, are protected by the lower rib cage Any patient with a penetrating thoracic wound (eg, javelin) at the level of the nipples or lower should be assumed to have an abdominal injury as well as a thoracic injury Similarly, blunt deceleration injuries, such as direct blows from a helmet or other body parts, can often injure both the thoracic and abdominal structures The thoracic spine consists of 12 vertical columns (vertebrae) connected by facet joints A disk with a lining and a center filled with a gelatinous substance lies between each of these vertebrae These disks act as shock absorbers and provide the spinal column with its flexibility When an athlete runs and jumps, these disks absorb the impact and prevent the vertebrae from grinding against one another Four muscle groups—the abdominals, the extensors, and sets of paraspinal muscles—control the thoracic spinal column Within the spinal cord is a massive trunk of nerves that runs down the length of the spinal column from the brain to the sacrum Smaller nerves branch out from the main trunk at each vertebra These nerves travel to the arms, torso, and legs The brain can send out electrical impulses through these nerves to the various tissues to make them function The brain can also receive feedback from the tissues through these nerves EVALUATION AND ASSESSMENT When evaluating an athlete with a possible thoracic injury, sports emergency care providers should always assume the worst because it is extremely important that potential life-threatening injuries are not overlooked During the initial evaluation, search first for the most serious injuries As with any athletic injury, the mechanism of injury is extremely important in caring for the most severe thoracic injuries Thoracic injuries may be the result of blunt or penetrating trauma Blunt trauma, which can occur in most contact sports, can result in a force being distributed over a Injuries to the Thoracic Region 125 large area, and visceral injuries occur from deceleration, shearing forces, compression, or bursting Penetrating injuries, which are less common, can occur from objects that are inadvertently on the field or court surface or objects that are airborne, such as a javelin The distribution of forces is typically over a much smaller area in penetrating injuries Oftentimes, thoracic injury causes tissue hypoxia Tissue hypoxia may result from the following: Inadequate oxygen delivery to the tissues secondary to airway obstruction Hypovolemia from blood loss Asymmetrical lung expansion Changes in pleural pressures from tension pneumothorax Pump failure from severe myocardial injury The major symptoms of chest injury include shortness of breath, chest pain, and respiratory distress The signs indicative of chest injury include shock, hemoptysis, cyanosis, chest wall contusion, flail chest, open wounds, distended neck veins, tracheal deviation, or subcutaneous emphysema Check the lungs for the presence, quality, and equality of breath sounds Life-threatening, sports-related thoracic injuries should be identified immediately Some sports-related thoracic injuries will be detected during the primary survey, whereas others may not be detected until a more detailed examination is conducted Injuries detected during primary survey Injuries more likely to be detected during the detailed examination Airway obstruction Tension/traumatic pneumothorax Spontaneous pneumothorax Massive hemothorax Flail chest Cardiac tamponade Traumatic aorta rupture Tracheal or bronchial tree injury Myocardial contusion Diaphragmatic tear Esophageal injury Pulmonary contusion Sternal fractures/contusion Rib fractures/contusions Costochondral separation/dislocation Thoracic spine fracture Thoracic muscle strains AIRWAY OBSTRUCTION Airway obstruction recognition is vital Airway management is a challenge that must be met in the care of the life-threatening sports injury Refer to Chapter for additional information on management of airway and breathing emergencies Finally, always assume a spinal injury in the unconscious, down athlete when securing the airway TENSION PNEUMOTHORAX A tension pneumothorax (sometimes known as traumatic pneumothorax) can occur when a one-way valve is created from either blunt or penetrating trauma Air can enter but cannot leave the pleural space This causes an increase in the intrathoracic pressure, which will collapse the 126 Chapter A B Figure 9-2 (A, B) Pneumothorax (Reprinted with permission from O’Connor DP, Fincher AL Clinical Pathology for Athletic Trainers: Recognizing Systemic Disease 3rd ed Thorofare, NJ: SLACK Incorporated; 2015.) lung and increase pressure on the mediastinum This pressure will eventually collapse the superior and inferior vena cava, resulting in a loss of venous return to the heart A shift of the trachea and mediastinum away from the side of the tension pneumothorax will also compromise ventilation of the other lung, although this is a late phenomenon Clinical signs of a tension pneumothorax include apprehension, agitation, cyanosis, diminished breath sounds and hyper-resonance to percussion on the affected side, cold clammy skin, distended neck veins, and hypotension (Figure 9-2) Tracheal deviation, or a shifting of the trachea toward the side of the functioning lung, is usually a late sign (if at all), and its absence does not rule out a tension pneumothorax SPONTANEOUS PNEUMOTHORAX When a pneumothorax occurs in the absence of any traumatic injury or disease, it is called a spontaneous pneumothorax This type of pneumothorax is rare in athletes but can be fatal if not appropriately detected and managed Diagnosis depends on a thorough understanding of possible presenting signs and symptoms, such as chest pain, dyspnea, and diminished breath sounds Regardless of whether a pneumothorax occurs spontaneously or from trauma, early and accurate diagnosis is essential The classic complaint of an athlete with a pneumothorax is chest pain The pain can be vague but is usually localized to the side of the affected lung and can radiate to the shoulder, neck, and/or back Often pain can be associated with dyspnea on exertion and/or a dry cough Other classic findings of pneumothorax include tachypnea, tachycardia, hyperresonance to percussion of the affected chest area, diminished breath sounds, and fremitus on the side of the affected lung Although the factors that cause or contribute to a spontaneous pneumothorax are not clearly understood, it has been suggested that a family history and a tall, thin body build can be associated factors Injuries to the Thoracic Region 127 Table 9-1 MANAGEMENT OF SPONTANEOUS AND TENSION PNEUMOTHORAX AND HEMOTHORAX Establish an open airway Activate EMS if not on the scene Treat for shock Provide supplemental oxygen (avoid positive pressure ventilation) Place in a position of comfort, or if lying, with affected side down (this occasionally helps) Monitor oxygen saturation with pulse oximeter Rapid transport to hospital Sports-related spontaneous pneumothorax has been documented in weight lifting, football, and jogging However, most cases of spontaneous pneumothorax are not related to exertion or activity Clinical signs of a spontaneous pneumothorax include apprehension, agitation, sharp unilateral chest pain, a history of vigorous coughing, and decreased lung sounds unilaterally This patient must be transported rapidly to the hospital so chest decompression can be performed (Table 9-1) A chest tube will also be necessary upon arrival to the hospital MASSIVE HEMOTHORAX A hemothorax occurs when blood enters the pleural space (Figure 9-3) A massive hemothorax occurs as a result of at least 1500 cc blood loss into the thoracic cavity Each thoracic cavity may contain up to 3000 cc of blood A massive hemothorax is more commonly caused by a penetrating trauma, but it can also occur from a blunt trauma Either mechanism of injury may disrupt a major pulmonary or systemic vessel As blood accumulates within the pleural space, the lung on the affected side is compressed If enough blood accumulates, the mediastinum will be shifted away from the hemothorax The inferior and superior vena cava and the contralateral lung are compressed Thus, the blood loss is complicated by hypoxemia Clinical signs and symptoms of massive hemothorax are produced by both hypovolemia and respiratory compromise The patient may be hypotensive from blood loss and compression of the heart or great veins Anxiety, apprehension, and confusion are the results of hypovolemia and hypoxemia Signs and symptoms of hypovolemic shock may be apparent followed by difficulty breathing The neck veins are usually flat, breath sounds are decreased or absent on the side of the injury, and chest percussion is dull FLAIL CHEST Flail chest is defined as a fracture of or more adjacent ribs in at least places (Figure 9-4) These injuries typically occur in contact sports like football, hockey, wrestling, and lacrosse In rare cases, they may occur from a severe torsion mechanism in a noncontact sport The result is a segment of the chest wall that is not in continuity with the thorax A lateral flail chest or anterior flail chest (sternal separation) may result With posterior rib fractures, the heavy musculature usu- 128 Chapter Figure 9-3 Hemothorax (Reprinted with permission from O’Connor DP, Fincher AL Clinical Pathology for Athletic Trainers: Recognizing Systemic Disease 2nd ed Thorofare, NJ: SLACK Incorporated; 2008.) Figure 9-4 Flail chest (Illustration by Joelle Rehberg, DO.) ally prevents the occurrence of a flail segment The flail segment moves with paradoxical motion relative to the rest of the chest wall The force necessary to produce injury also bruises the underlying lung tissue, and the pulmonary contusion can also contribute to hypoxia The patient is at risk for the development of the other conditions already discussed in this chapter (hemothorax or pneumothorax) With a large flail segment, the patient may be in marked respiratory distress Pain from the chest wall injury exacerbates the already-impaired respiration from paradoxical motion and the underlying lung contusion Palpation of the chest may reveal crepitus in addition to the abnormal respiratory movement Management of flail chest includes stabilizing the flail segment with manual pressure or a bulky dressing or pillow secured to the chest Treat for pneumothorax or hemothorax if signs and symptoms are present TRACHEAL OR BRONCHIAL TREE INJURY Injuries to the trachea or bronchial tree are rare in sports because they are usually the result of a penetrating or blunt trauma The signs and symptoms must be recognized because it can be a fatal condition Penetrating upper airway injuries can be associated with major vascular injuries and extensive tissue destruction Signs and symptoms include shortness of breath, mediastinal shift, subcutaneous emphysema, and hemoptysis Mechanism of injury and history are vital, and the clinical finding may be subtle In this blunt injury, either the trachea or mainstream bronchus will be ruptured The signs that may be present include subcutaneous emphysema of the chest, face, or neck or even associated pneumothorax or hemothorax Injuries to the Thoracic Region 129 Management of tracheal or bronchial tree injury includes maintaining an open airway, activating emergency medical services (EMS) if not already on scene, administering high-flow supplemental oxygen, and transporting the athlete to the hospital immediately DIAPHRAGMATIC TEARS Tears in the diaphragm may result from a severe blow to the abdomen and can occur in a large variety of sporting events A sudden increase in intra-abdominal pressure, such as a kick, punch, or elbow to the abdomen, may tear the diaphragm and allow herniation of the abdominal organs into the thoracic cavity This occurs more commonly on the left side than the right side because the liver protects the right diaphragm The blunt trauma may produce large radial tears in the diaphragm Penetrating trauma may also produce holes in the diaphragm, but those tend to be small This injury may be difficult to diagnose, even in the hospital The clinical signs may include marked respiratory distress, diminished breath sounds, and infrequent bowel sounds, which may be heard when the chest is auscultated The abdomen may present a sucked-in appearance if a large quantity of abdominal contents is in the chest Management for diaphragmatic tears includes treating for shock, assisting with breathing, administering supplemental oxygen, and immediately transfering to a medical facility ESOPHAGEAL INJURY Injury to the esophagus is usually produced by a penetrating trauma and is rare in sports However, sports emergency care personnel must be able to recognize this injury because it can be fatal if unrecognized Signs and symptoms of esophageal injury include stridor, hoarseness, dysphagia, subcutaneous emphysema, and oropharyngeal/nasopharyngeal bleeding Management of associated trauma is extremely important as well Treat for shock, provide supplemental oxygen, and package the patient as soon as possible and transport to a hospital because operative repair will be required for this injury PULMONARY CONTUSION A pulmonary contusion is a common injury that occurs from blunt trauma Bruising of the lung results from passage of a shockwave through the tissue Injuries involving high velocity rather than slow crushing are more likely to cause pulmonary contusion Contusion of the lung may produce marked hypoxemia Pulmonary contusions are rarely diagnosed on physical examination The mechanism of injury may suggest blunt chest trauma, and thus there may be obvious signs of chest wall trauma such as bruising, rib fractures, or flail chest These suggest the presence of an underlying pulmonary contusion Crackles may be heard on auscultation but are rarely heard in the emergency room and are nonspecific Patients with pulmonary contusions should be referred to a physician for further evaluation STERNAL FRACTURE/CONTUSION Sternal fractures result from a high-impact blunt trauma to the chest Although it is more common in automobile accidents than in sports, it can still occur in sports Sports emergency care personnel must be aware of this injury because it can result in an injury to the underlying cardiac muscle Clinical signs and symptoms of this injury include point tenderness over the sternum that will worsen with deep inspiration or forceful expiration Signs of shock may indicate an injury to the underlying tissue In the field, it is difficult sometimes to differentiate between the sternal contusion and fracture, and radiography will help make the differential diagnosis 130 Chapter RIB FRACTURES AND CONTUSIONS Rib contusions are common in sports These injuries occur more frequently in collision sports like football, hockey, lacrosse, and wrestling but can also occur is other sports A direct blow to the rib cage can contuse intercostal muscles or fracture them if the blow is severe enough Because the intercostal muscles are essential to breathing, the athlete may experience sharp pain with expiration, inspiration, coughing, laughing, or sneezing There will be point tenderness over the rib cage and pain with compression of the rib cage Rib fractures are especially common in collision sports Fractures can be caused by direct and indirect trauma Ribs through are the most commonly fractured The direct-blow rib fracture causes the most serious damage because the external force fractures and displaces the ribs inward Such a mechanism may completely displace the bone and cause fragmentation The fragments may cut, tear, or perforate the tissue of the pleurae (hemothorax) or collapse one lung (pneumothorax) Contrary to the direct injury, the indirect fracture usually causes the rib to fracture outward, producing an oblique or transverse fracture Stress fractures can also occur Repetitive movements like throwing or rowing or repetitive coughing or sneezing can result in a rib stress fracture Rib fractures are either easily detectable due to a deformity or difficult to detect An athlete should always be examined thoroughly for any underlying conditions that may occur The athlete should be stabilized and immediately transported to a medical facility if there is a possibility of an unstable fracture COSTOCHONDRAL SEPARATION/DISLOCATION Costochondral separations occur from a direct blow to the anterolateral aspect of the thorax or indirectly from a sudden twist or fall on a ball that compresses the rib cage The costochondral injury displays many signs that are similar to the rib fracture, with the exception of the location of the pain The pain will be localized in the junction of the rib cartilage and rib The athlete will complain of sharp pain with sudden movement of the trunk and difficulty breathing deeply There is point tenderness Management of costochondral separations and dislocations includes ice and referral to a physician for follow-up THORACIC SPINE FRACTURE Thoracic spinal fractures can occur whenever forces exceed the strength and stability of the spinal column Thoracic spine fractures are uncommon in sports but need to be recognized because spinal cord injuries represent the second most serious long-term morbidities resulting from thoracic trauma, with traumatic aortic rupture being the first Fractures most commonly occur in the lower thoracic vertebrae and are less common in the upper and mid-thoracic vertebrae The ribs and the orientation of the facets stabilize the upper thoracic spine (T1–T10) However, at the T12–L1 junction, increased range of motion allows combinations of acute hyperflexion and rotation The mechanisms of thoracolumbar spine trauma are hyperflexion, vertical compression, hyperextension, and shearing injury Hyperflexion injury includes flexion with compression, lateral flexion, flexion-rotation, and flexion-distraction injuries These mechanisms can occur in collision sports and some noncontact sports A vertical compression mechanism results in burst injuries of the vertebral body Hyperextension injuries result in posterior spinal compression fractures, whereas shearing injury can cause subluxation or dislocation of the spinal column Signs and symptoms the athlete may experience with a thoracic spine injury include pain or point tenderness in the thoracic region or paralysis below the chest or waist The lower extremities may be cool Injuries to the Thoracic Region 131 MANAGEMENT OF THORACIC SPINE INJURY/TRAUMA Maintain spinal immobilization Establish an open airway Activate EMS Treat for shock Administer high concentration oxygen Monitor oxygen saturation with a pulse oximeter Transport the athlete rapidly to a hospital Notify medical direction THORACIC OUTLET SYNDROME Thoracic outlet syndrome is a group of disorders that occur when blood vessels or nerves in the space between the collarbone and the first rib (thoracic outlet) are compressed This can cause pain in the shoulders and neck and numbness in the fingers Common causes of thoracic outlet syndrome include physical trauma from a car accident, repetitive injuries from job- or sports-related activities, certain anatomical defects (eg, having an extra rib), and pregnancy Sometimes doctors cannot determine the cause of thoracic outlet syndrome Management of thoracic outlet syndrome includes pain modification interventions and a referral to an appropriate health care provider for further evaluation Treatment usually involves physical therapy and pain relief measures Most people improve with these approaches However, in some cases a doctor may recommend surgery CHRONIC THORACIC INJURY Some thoracic injuries are chronic in nature After participating in sports, a person may report pain in the thoracic region that may not be the result from one acute mechanism of injury These conditions may include the following: Thoracic spine muscle spasms: Muscle spasms in the mid-back (thoracic) region are common and are often described as a sharp stabbing pain A mid-back spasm can also be caused by an athletic injury, an injury from an accident, or overuse Usually, the fundamental cause of a mid-back spasm that triggers pain or a “back attack” will have a local origin However, that does not mean that it is easy to identify It is important to understand that the structure of the thoracic spine is complicated Management of an acute muscle spasm should be ice to control the initial pain and referral to an appropriate health care provider for further evaluation to determine the underlying cause of the injury Thoracic spinal stenosis: A narrowing of the spinal canal in the middle of the back is known as thoracic spinal stenosis This degenerative spine condition can involve any of the 12 thoracic vertebrae, which are numbered T1 to T12 Symptoms of thoracic spinal stenosis may include the following: Pain in the ribs Pain in the affected area of the back 132 Chapter Pain radiating down the back or legs Aching in the legs that leads to difficulty walking Pain in one or more internal organs Management of thoracic spinal stenosis should be ice to control the initial pain and referral to an appropriate health care provider for further evaluation to determine the underlying cause of the injury Thoracic scoliosis: The thoracic spine is the most common location for a scoliotic curve Thoracic scoliosis more commonly presents itself as a curve to the right (dextroscoliosis), and as with all types of scoliosis, it is more common in female patients than in male patients CONCLUSION Most thoracic injuries, although rare in sports, can be life-threatening in nature It is important to recognize these life-threatening conditions because it is vital that the athlete receives prompt intervention, EMS activation, and transport to the nearest hospital It is extremely important that most of the injuries in this chapter are recognized by the sports medicine team and treated properly in the field because it may help save the athlete’s life SUMMARY OF KEY POINTS Acute thoracic injuries can be among the most serious in sports because they can impose a threat of long-term disability and, in the most severe cases, even death A tension pneumothorax can occur when a one-way valve is created from either blunt or penetrating trauma A spontaneous pneumothorax is a rare condition found occasionally in athletes, and it occurs in the absence of trauma or disease A hemothorax occurs when blood enters the pleural space Flail chest is defined as a fracture of or more adjacent ribs in at least places, and it typically occurs in contact sports like football, hockey, wrestling, and lacrosse Penetrating upper airway injuries to the trachea or bronchial tree can be associated with major vascular injuries and extensive tissue destruction Tears in the diaphragm may result from a severe blow to the abdomen, causing a sudden increase in intra-abdominal pressure Esophageal injuries are produced by penetrating trauma and are rare in sports A pulmonary contusion is a common injury that occurs from blunt trauma and may produce marked hypoxemia Sternal fractures result from a high-impact blunt trauma to the chest Rib contusions and fractures are common in sports These injuries occur more frequently in collision sports like football, hockey, lacrosse, and wrestling and cause sharp pain with expiration, inspiration, coughing, laughing, or sneezing Rib fractures are either easily detectable due to a deformity or difficult to detect Costochondral injury displays many signs that are similar to the rib fracture, with the exception of the location of the pain The pain will be localized in the junction of the rib cartilage and rib Thoracic spine fractures are uncommon in sports but need to be recognized because spinal cord injuries represent the second most serious long-term morbidities resulting from thoracic trauma, with traumatic aortic rupture being the first Injuries to the Thoracic Region 133 Thoracic outlet syndrome is seen in sports and can be from an acute mechanism or chronic in nature Treatment for thoracic outlet syndrome usually involves physical therapy and pain relief measures Most people improve with these approaches However, in some cases a doctor may recommend surgery Some thoracic injuries are chronic in nature After participating in sports, a person may report pain in the thoracic region that may not be the result from acute mechanism of injury REVIEW QUESTIONS Define tension pneumothorax, spontaneous pneumothorax, and hemothorax What is the proper care for flail chest? What are the signs and symptoms of a pulmonary contusion? What is the most common mechanism of injury for a thoracic spinal fracture? What is the most important concern in managing a tracheal or bronchial tree injury? BIBLIOGRAPHY Anderson MK Foundations of Athletic Training: Prevention, Assessment and Management 4th ed Baltimore, MD; Lippincott Williams and Wilkins; 2009 Campbell JE BTLS, Basic Trauma Life Support for the EMT-B and the First Responder Upper Saddle River, NJ: Pearson Prentice Hall; 2004 Ciocca M Jr Pneumothorax in a weight lifter: the importance of vigilance Phys Sportsmed 2000;28(4):97-103 Curtin SM, Tucker AM, Gens DR Pneumothorax in sports: issues in recognition and follow-up care Phys Sportsmed 2000;28(8):23-32 Copass MK, Gonzales L, Eisenberg MS, Soper RG EMT Manual 3rd ed Philadelphia, PA: WB Saunders Co; 1998 Micheli LJ The Sports Medicine Bible New York, NY: Harper Perennial; 1995 Nichols AW The thoracic outlet syndrome in athletes J Am Board Fam Pract 1996;9(5):346-355 Prentice W Principles of Athletic Training: A Competency-Based Approach 14th ed New York, NY: McGraw Hill; 2011 ... LCCN 2 018 022460 (print) | LCCN 2 018 02 318 7 (ebook) | ISBN 97 816 30 914 349 (Epub) | ISBN 97 816 30 914 356 (Web) | ISBN 97 816 30 914 332 (paperback) Subjects: | MESH: Athletic Injuries therapy | Emergency. .. proficient in sports emergency care WHAT IS SPORTS EMERGENCY CARE? Emergency care is defined as the immediate care given to an injured or suddenly ill person Practitioners of emergency care must... Emergency Treatment Classification: LCC RC1 210 (ebook) | LCC RC1 210 (print) | NLM QT 2 61 | DDC 617 .1/ 027 dc23 LC record available at https://lccn.loc.gov/2 018 022460 For permission to reprint material